Healthcare Provider Details

I. General information

NPI: 1134050511
Provider Name (Legal Business Name): KAMERON BETHANY GOTTLIEB PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 S PARK ST
MADISON WI
53715-1708
US

IV. Provider business mailing address

2725 MARSHALL CT APT 304
MADISON WI
53705-2288
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-3111
  • Fax:
Mailing address:
  • Phone: 847-440-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: